Tuesday, January 31, 2012

Just the other day, my wife and I went for a walk with some new friends. As we were saying goodbye, one of our friends innocently asked, "So, how many hours do you work at the hospital?" While his question was well-meaning, it once again belied the fact that so many people make wild assumptions about nurses and nursing, and most everyone has little idea what nurses actually do. I've expounded on this topic before here on Digital Doorway, so why not expound some more?

Our newly birthed internet radio station for nurses---RN.FM Radio---is maturing into a reliable weekly source of inspiration, encouragement, interviews and nursing news that many nurses are flocking to every Monday evening at 9pm EST.

I am a nurse, coach, nurse blogger and professional writer, and I have
been following the case of Amanda Trujillo quite closely.

Having read the legal brief, Ms. Trujillo's statements, as well as other
facts about the case, it is clear to me that Ms. Trujillo was acting
completely within her scope of practice as a nurse when she provided the
patient in question with information regarding her choices vis-a-vis
her pending surgical intervention.

The fact that Ms. Trujillo is now being forced to undergo a psychiatric
evaluation further supports the contention that no stone is being left
unturned in efforts to undermine her credibility and her history as an
exemplary nurse. It is ironic that the surgeon who demanded the
suspension of her license and her ability to practice in the state of
Arizona is undergoing no such evaluation or rigorous vetting process.
The Arizona Board of Nursing and Ms. Trujillo's employers easily caved
to demands by the surgeon that Ms.Trujillo be fired and lose her
license, an action that once again demonstrates how the disparity of
power between physicians and nurses continues to undermine nurses'
ability to perform their duties according to a clearly stated scope of
practice.

Ms. Trujillo was taken to task for "messing up" the surgeon's "hard
work" of preparing for the scheduled surgery. Why was Ms. Trujillo not
praised for providing necessary education to a patient who clearly
demonstrated a startling knowledge deficit regarding what this surgery
would entail for her? Nurses are trained to provide education and
resources to patients, and that includes situations wherein physicians
themselves fail to educate patients properly. Ms. Trujillo may have
"messed up" this physician's "hard work", but she refused under these
circumstances to "mess up" this patient's life by failing to educate her
and provide the information that would elicit true informed consent,
something that the physician in question clearly failed to accomplish.

The nursing community is rallying around Ms. Trujillo due to the facts
that clearly demonstrate how Ms.Trujillo acted within her scope of
practice and documented her actions clearly and concisely following her
interactions with the patient. If the physician was inconvenienced by
her actions, this issue could have been addressed by the facility's
ethics committee. Instead, the Board of Nursing and Banner Health agreed
to the physician's outrageous demands, allowing his power to prevent a
measured and intelligent response to the situation at hand.

It would indeed have a chilling effect on the entire nursing profession
if the Arizona Board of Nursing sets a precedent that redefines our
profession and the collaborative health care model that has been the
touchstone of professional nursing for decades.

As you by now understand, the actions against Ms. Trujillo and the
suspension of her nursing license have ignited a firestorm of criticism
regarding how this case has been handled by both the Arizona Board of
Nursing and Ms. Trujillo's employer. The support is only
growing, and those who are incensed by this situation will use the power
of social media and the traditional media to bring the egregious nature
of this case to the attention of the wider public.

I respectfully request that you consider dropping the complaint filed
against Amanda Trujillo’s license and the case against her.

To whom it may concern,
In the case of Amanda Trujillo, RN, a profoundly negative and chilling
precedent threatens to silence nurses in their efforts to uphold their
solemn oaths to protect, educate and advocate for their patients.

Additionally, a patient’s Right to Know and Right to Self-Determination are directly in jeopardy.

National Nursing groups, Patients’ Rights Advocacy groups, and the
media have been put on alert and are watching this case carefully,
hoping that the AZ BON makes the right choice to support the education
and interventional activities of a nurse, who discovered a severe
knowledge deficit in her patient and operated within her scope to
rectify it.

It would be a shameful to set a precedent that re-defines our
profession and the collaborative health care model that we thought we
operated in for the good of our patients.

I respectfully request that you consider dropping the complaint filed
against Amanda Trujillo’s license and the case against her.

Tuesday, January 24, 2012

Some readers of Digital Doorway may have already heard the story of Amanda Trujillo, an Arizona nurse who has lost her license based on nursing actions taken that were apparently fully within her scope of practice.

In the course of caring for a patient who was facing the potential of a liver transplant, Amanda offered this patient information regarding the availability of hospice as an alternative to this risky surgery with an uncertain outcome. It was clear to Ms. Trujillo that the patient did not understand the risks involved in this procedure, and she saw it as her professional duty to provide the appropriate resources and referrals to the patient so that she could make a fully informed decision. The patient subsequently chose to not undergo the procedure, and the physician who had planned and scheduled the surgery filed a complaint against Amanda and demanded that her license to practice be revoked.

Many of us in the nationwide nursing community are advocating for Amanda, and calling for the Arizona State Board of Nursing to cease and desist their actions which have deprived Amanda of her nursing license, brought her before the Board for disciplinary action, and requiring that she undergo a psychiatric examination. These actions are depriving Amanda and her daughter (she is a single mother) of their means of financial support, putting this small family at great risk of economic disaster.

The following is an open letter to the Arizona Board of Nursing, and was written by Kevin Ross of Innovative Nurse. I echo Kevin's sentiments, and urge all nurses and non-nurses who support Amanda's right to practice as a nurse to contact the Arizona Board of Nursing at 602-771-7800 or arizona@azbn.gov, informing them that we are watching this case closely and will not allow Amanda to be treated unfairly or unjustly.

Below Kevin's letter is a legal briefing describing the events in question. After reviewing the case details, please feel free to contact the Arizona State Board of Nursing on the behalf of Ms. Trujillo. The Board can be reached at 602-771-7800 or arizona@azbn.gov.

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An open letter to the Arizona State Board of Nursing.

Disclaimer, I have not been directly contacted by Amanda Trujillo,
MSN, RN, DNSc-NP(s), nor do I know her personally or professionally. I
am also writing to you based on the information that I have available to
me.

To the Arizona State Board of Nursing:

To whom it may concern,

I am writing to you on behalf of Amanda Trujillo, MSN, RN, DNSc-NP(s)
regarding the case attached below. I have not been contacted directly
by Amanda Trujillo, and I have neither a personal or professional
relationship other than that she is a fellow nurse in need of my
support.

Based on the information I have (to my knowledge the same case
documents that you also have), I would like to ask the board to
carefully consider the information presented by both Ms. Trujillo and
her legal team. From my understanding, it appears that Amanda Trujillo
evaluated the health status of her patient based on her own clinical
assessments and also data collected while being treated by the medical
team at Ms. Trujillo’s place of employment during this time. It also
appears from the information that Amanda Trujillo provided health
teaching, counseling, and advocacy for her patient, which to my
understanding of the Nurse Practice Act is well within her scope of
practice.

As a nurse and patient advocate, I make certain that each and every
patient I provide services to does in fact receive the highest quality
nursing care while on my case. It should go without saying, but part of
this care involves my ongoing support to ensure that my patient is
knowledgeable about their diagnoses, medications, and ordered treatment
plan. It is my job to protect the health and safety of each and every
patient that I come into contact with, and to advocate for their needs
based on my clinical judgement.

I am not in any way assuming that the treating physician was
negligent, however considering that this is, and should have been a
collaborative approach in the patient’s care, Amanda Trujillo was making
her own nursing diagnosis based on her clinical assessment, which again
to my knowledge is within her scope of practice as a registered nurse.
She apparently discovered a deficit in her patient’s knowledge about
their treatment options, and it appears that she acted ethically in
supporting her patient’s wishes to seek additional information, and
referred the patient to a case management specialist as per protocol.

I realize that these cases can carry with them a great deal of
emotion due to the sensitive nature that our number one priority as
licensed nurses is to protect our patient’s health and safety. It seems
that Amanda’s duty to uphold the rights of her patient is being
challenged, and the circumstances in which this transpired seems to have
been initiated and fueled by emotion, and not based on facts. I just
ask that you please consider all of the information presented to you,
evaluate this case objectively, and if Amanda Trujillo is exonerated
from these allegations, that she have the opportunity to continue to
practice professional nursing.

Thank you in advance for your time and your consideration in this matter.

Respondent Amanda Trujillo, by and through undersigned counsel,
submits this Description of Events in response to a complaint filed
against her in June of 2011 with the Arizona State Board of Nursing
(“Board”) by Banner Del E. Webb Medical Center (“Webb”).

Description of Relevant EventsThe allegations contained in the complaint arise from events that
occurred on April 12th, 2011, when Ms. Trujillo was caring for a patient
with end stage liver disease in the 3D Telemetry unit of Webb. Ms.
Trujillo had been a registered nurse with Webb for approximately six
months prior to the date of the alleged conduct and she normally worked
the night shift from 7 a.m. to 7 p.m.

After assessing and communicating with the patient, Ms. Trujillo’s
evaluation led her to believe that the patient did not fully understand
what she had consented to when (pt) agreed to go forward with an
intensive transplant evaluation scheduled to begin at Banner Good
Samaritan Medical Center the following day. Based on her nursing
assessment, Ms. Trujillo gathered patient education materials and spoke
with the patient regarding the transplant evaluation, the waiting
period and the commitment needed in following a lifelong self-care
regimen. After their discussion, the patient expressed a desire to
learn more about hospice care because (pt) was uncertain she was willing
to take the necessary steps to maintain a successful organ transplant.
Thus, the patient inquired into whether (pt) could speak with a hospice
representative. Ms. Trujillo then placed an “order” for a case
management consult with a hospice representative. Ms. Trujillo did not
believe that requesting a case management consult was a medical order
requiring physician permission; she believed the consultation was for
educational purposes in order to give the patient a broad understanding
of her options.

As a result of the additional information given by Ms. Trujillo, the
patient determined (pt) did not want to go through with the liver
transplant evaluation or resulting transplant procedure. When the
doctor treating the patient found out about the patient’s wishes to
forgo the evaluation he was unhappy that the patient had changed
(pts) mind and determined that the education given by Ms. Trujillo was
the underlying cause of the patient’s change of heart. He accused her
of going beyond her scope of practice by entering a physician order
without permission (“ordering” the case management consultation). As a
result of the accusation, Ms. Trujillo was placed on administrative
leave by her nursing director, Venus Gaines, and was eventually
terminated by Webb.

Ms. Trujillo believes she was well within her scope of practice to
assess the patient’s understanding of (pts) plan of care. She was not
acting outside her scope of practice by educating the patient (deferring
all questions outside of her scope to the medical team), once she
determined the patient had a gross misunderstanding of what (pt) had
agreed to participate in. Ms. Trujillo believed that the case
management “order” she placed on the patient’s behalf was not a medical
order that needed physician permission. Each step of the treatment
provided by Ms. Trujillo to the patient will be analyzed below.

Patient AssessmentIt is standard practice for Ms. Trujillo to ensure her patients
understand their medications, plan of care and treatments. While fully
reviewing the patient’s medical record Ms. Trujillo read a progress note
entered by the patient’s primary care physician from earlier in the day
that noted a “transplant evaluation is the only viable option outside
of Hospice.” Utilizing the standard nursing process of patient
assessment (assessment, diagnosis, planning, intervention, evaluation),
Ms. Trujillo asked the patient a number of open-ended questions
regarding (pts) hospital stay, medications, liver disease, procedures,
etc. Ms. Trujillo asked the patient if (pt) had received any
information or teaching regarding the proposed transplant evaluation.
The patient, to Ms. Trujillo’s surprise, responded that (pt) did not
understand (pts) disease, plan of care or what a transplant evaluation
entailed. The patient asked Ms. Trujillo if she could provide some
information regarding the disease and any less invasive choices that
would allow (pt) to go home and be with (pts) family. Based on this
request Ms. Trujillo determined the patient had a knowledge deficit
regarding (pts) disease and the choice to receive palliative care.

Patient EducationHaving assessed the knowledge deficit related to the patient’s
routine medications, disease process, associated tests and procedures,
the plan of care for transplant evaluation and palliative care options,
Ms. Trujillo proceeded to print out patient educational material from
Banner’s website that addressed those areas. Additionally, she printed
out education materials from Banner’s transplant website pertaining to
what to expect during a transplant evaluation and what to expect after a
transplant. Ms. Trujillo also provided materials related to hospice
care per the patient’s request. Ms. Trujillo, concerned about the
patient’s lack of understanding of (pts) treatment regimen and the
option for comfort care, discussed her education of the patient with her
clinical manager, Frances Fausto, who readily supported Ms. Trujillo’s
plan of care and interventions.

Ms. Trujillo and the patient reviewed the materials over the course
of the night. After a full review of the materials the patient stated,
“Had I known everything I would have to go through and the commitment I
would have to make, I would not have agreed to the transplant
evaluation.” The patient inquired into whether there was anything else
(pt) could do besides enduring more tests, procedures or surgeries. Ms.
Trujillo then explained hospice care services and the differences
between symptom relief care and end of life care. The patient expressed
serious concern that (pt) would not be able to commit to an extensive
aftercare regimen following the transplant by stating “at this stage in
(pts) life (pt) just wanted to be around family.” The patient requested
to visit with a representative from hospice in order to ask some
questions and gain additional information that would assist (pt) in
making a more informed decision regarding (pts) course of care.

Ms. Trujillo placed a note in the chart pertaining to the assessment
of knowledge deficit, the specific education provided and the palliative
care discussion, in addition to, the patient’s request to see a case
manager from hospice. She used the SBAR (Situation, Background,
Assessment and Recommendation) format of report required in Banner
policy when she handed off care of the patient to the dayshift nurse,
alerting the nurse that the patient requested more information prior to
being transferred to another facility for a transplant evaluation. She
also alerted the dayshift nurse that there was a nursing note in the
record for the doctor to read that detailed what occurred over the
course of Ms. Trujillo’s shift with the patient.

Case Management ConsultAs a relatively new nurse to Banner, Ms. Trujillo self-educated in
order to work within Banner’s policies and procedures. She found no
specific policy or procedure regarding end of life care that prohibited
her from obtaining case management consultations for her patients. She
also could not find any policy or procedure that gave a formal
definition of a “physician order” or what nurses could order and what
they could not. In fact, Ms. Trujillo had ordered hospice consultations
for her patients on numerous occasions prior to this incident without
any objections from other physicians or Webb administration. She
entered the “order” with a note stating, “per patient request, patient
wants to visit with hospice representative for more information.” In
fact, the computer system in place at Webb allows her to click a box
that further specifies “Nurse Ordered,” which she did on this occasion.

The only reason Ms. Trujillo’s actions turned into allegations of
unprofessional conduct is because the primary care physician on this
case, The Dr. initiated an angry public display when he found out that
the patient had changed (pts) mind regarding the transplant. Ms.
Trujillo was surprised when the nursing director, Venus Gaines, went so
far as to tell Ms. Trujillo that the physician was angered because she
had, “messed up all of the work they had done, and that the doctors were
nowhere near going down the hospice route.”

ConclusionThis was not a medical order. This was a nurse trying to help a
patient become better informed about a life changing procedure and (pts)
right to choose what direction (pts) care would go. Ms. Trujillo’s
actions were well within her scope of practice and she conscientiously
kept her line of teaching within the boundaries of her scope of practice
by taking care to utilize the proper channels to obtain patient
teaching materials and advising the patient to ask the doctors about
more complex questions she was unable to answer as a registered nurse.

The patient had the absolute right to self-determination regarding
her course of treatment, as illuminated in Senate Bill S. 1052, the
Bipartisan Patient Protection Act, after receiving additional
information regarding her disease. Ms. Trujillo, working within her
scope of practice and the nurse’s code of ethics, honored and protected
that right when she abided by the patient’s requests to the best of her
ability.

Accommodating a patient’s request for a consultation with a hospice
case manager does not require a physician’s order. No medication was
requested, no equipment was needed, and no procedures were required. A
patient simply wanted to speak with an expert regarding her options for
comfort care and end of life care, so that (pt) could make the best
decision about (pts) future.

It is standard knowledge that the Cerner electronic health records
system in place at Webb contains a box that states, “Nurse Ordered.”
Why would this box exist if nurses were never allowed to “order”
anything? The Complainant contends that Ms. Trujillo overstepped her
scope of practice by ordering the consult; however, it is standard
practice of the hospital to allow nurses the freedom to do the exact
thing alleged in the Complaint.

Ms. Trujillo was allowed to order case management consults on
numerous occasions prior to this and was never told by the hospital that
this practice was not allowed or outside the scope of her practice. It
is apparent that the hospital is simply trying to appease and placate
an angry physician by filing this Complaint against Ms. Trujillo.

She looks forward to discussing this matter with the Board, if necessary, and hopes to conclude this matter expediently.

Thursday, January 19, 2012

As always, I begin my book reviews with the disclosure that I did not receive financial compensation of any kind for this review,
but did receive a free copy of this drug guide from Majors Books in order to facilitate the
review process. --------
Some frequent readers of Digital Doorway will recall that I posted a review of the Nursing 2012 Drug Handbook on November 22nd of last year, and I was quite pleased with the overall layout and presentation of that particular drug guide for nurses. Since I happen to have both the Nursing 2012 Drug Guide and my review of said book in the forefront of my mind, the following review of Davis's Drug Guide for Nurses will be written as I take the differences and similarities between these two recently published drug guides for nurses into consideration.

General layout

The 12th edition of Davis's Drug Guide for Nurses appears to be extremely similar to its brethren, both in size, layout and general offerings.

Both Davis's guide and Nursing 2012 use almost the exact same color scheme for their drug monograph pages, with slight differences in font size and type. I find Nursing 2012 slightly easier on the eye in terms of font choice, but Davis's is also relatively readable without strain.

Drug monograph layout

Comparing drug monograph layout, there is generally little difference between these nursing drug guides, but I will take the time to elucidate several small differences which may or may not have a great impact on the user.

If we consider indications and dosages, I appreciate that Nursing 2012 combines both of these attributes of every drug at the beginning of each drug monograph, clearly delineating the pertinent details for both adults and children. Meanwhile, Davis's guide lists indications first and offers dosages and routes much later in each monograph. Personally, I prefer having the dosages and indications up front as soon as I begin reading about a drug, but the publishers and writers at Davis seem to feel that action, pharmacokinetics, contraindications and precautions, adverse reactions, side effects and interactions come first. I assume it is a matter of personal preference.

The Davis drug guide uses a red maple leaf symbol to specify medications that apply specifically to Canadian clinicians and
nursing practice. This is a nice touch, and our Canadian brethren may
very much appreciate this attention to detail on their behalf.

Both
books include the steps of the nursing process within the monographs,
warnings regarding interactions of drugs with foods and herbs, and
various aspects of IV medication administration.

Drug photographs

Many drug guides now offer photographs of commonly used medications, and this can be an invaluable tool for identification of medications and patient education. Nursing 2012 offers a photo guide to 396 common tablets and capsules. The photographs are full color, life-size, alphabetized, and located in the center of the book. The edges of the pages are shaded a different color so that this section can be handily and quickly utilized.

Davis's Drug Guide offers photographs only of medications with "Tall Man Lettering Changes" which have been recently mandated by the FDA. There are 33 medications with look-alike names and spellings which have now been changed to identify them and reduce confusion and medication errors. Examples of these "Tall Man" lettering changes are CycloSPORINE and CycloSERINE or GlipiZIDE and GlyBURIDE.

While having these mandated changes delineated clearly for readers is an excellent edition that Nursing 2012 lacks, having photographs of only 33 medications compared to the 396 medications displayed photographically in the Nursing 2012 Drug Handbook leaves little room for comparison. Nursing 2012 wins hands down for its use of photographic images.

Of note, the photographs of the "Tall Man" drugs in Davis's book are lumped together with other sections of special information. The edges of the pages of all of these special information sections are shaded with the same color, thus the pages of medication photographs are awkward to find and consequently less than handy.

Digital Offerings

The Davis guide comes with a CD -ROM (compatible with both PC and Mac) that offers an audio library of drug names, a drug search program, updated tutorials on medication errors, wound care and psychotropic drugs, as well as calculators for BMI, metric conversions, IV drip rates, and other features. There is also a free mobile device download of 100 drug monographs and resources available online at DavisPLUS.

Meanwhile, Nursing 2012 delivers access to an online drug advisor, patient teaching sheets, CEUs, as as well as detailed monographs of every drug listed in the book and some medications not included in the print version. This can all mostly be downloaded or viewed on a mobile device. Still, I feel it would behoove the publishers of Nursing 2012 to consider the addition of a CD-ROM in subsequent editions.

The Summing Up

For overall readability, layout and design, I definitely prefer the Nursing 2012 Drug Handbook over Davis's Drug Guide for Nurses, Twelfth Edition. Nursing 2012's inclusion of far more photographic images of medications and its slightly better font choices make it preferable for me, however Davis's inclusion of the CD-ROM, Canadian specifications and "Tall Man" lettering changes mandated by the FDA are also important features to consider.

These two guides are quite comparable, and both offer nurses the information they need in not dissimilar formats and designs. In terms of most of the differences, personal preference may be the deciding factor for many nurses. And for those enamored of the photographic images of drugs, Nursing 2012 is the best choice. Still, a prudent nurse cannot go wrong with either guide, and both will certainly lend themselves to safer care, fewer medication errors, and nurses who have the information they need at their fingertips.

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If any readers of Digital Doorway would like a 10% discount on the Davis Drug Guide from Majors Books, please use the code "nursekeith" when checking out. This offer is valid for 30 days. I receive no compensation for sales of this book through Majors Books. This is simply a gift to my readers from me, and a thank you from Majors Books for the review.

That said, the first commenter on this post who can tell me the name of two famous nursing theorists and their main theories of nursing will win a copy of Davis's Drug Guide for Nurses from me! The winner will be announced within the "comments" section, and that individual will need to send their mailing address to kc@nursekeith.com.

Wednesday, January 18, 2012

Well, it may seem like a blink of an eye at times, but Digital Doorway has been alive and well for seven years today, born from a simple suggestion by my prescient brother as we sat in front of the woodstove on a snowy New England night. I can hardly believe that so much time has passed since that January day when I dived headfirst into the blogging world with no idea of where I was going or, honestly, what I was doing.

When Digital Doorway launched, it was not clear to me that it would be a blog mostly about nursing. Although my online moniker at the time was indeed "Nurse Keith", I had no notion of branding, hadn't heard of SEO (Search Engine Optimization), and the blogosphere was an enormous and cavernous unknown.

Over time, Digital Doorway began to distill itself into a somewhat more cohesive entity, and 1520 posts later, it has become one of the more well-known blogs in the nursing blogosphere,. Yes, it's garnered a fair amount of attention and notoriety over time, although it's still somewhat small potatoes compared to the blogging giants out there. (You know who you are!)

Back in the day, I didn't know about keywords and never gave much thought to such things. In all actuality, I still don't write my posts with keywords in mind, and I just let my blog's relative influence online do the job. However, with hundreds of backlinks that point here to Digital Doorway, it's a given that my writing will have a moderate audience out there in blogland. That said, with my new mentors, colleagues and friends over at RN.FM Radio,
keywords, SEO and such animals are now making their way into my lexicon
and writing practice, and as we grow RN.FM Radio and its cousin LLC,
Unbound Media Group, our presence online as coaches, bloggers and nurse
entrepreneurs is sure to grow. And no doubt that Digital Doorway will itself benefit from that vertical and horizontal expansion.

As NurseKeith.com continues its slow and steady launch, Digital Doorway is becoming the repository of much more focused thoughts on nursing, the profession's present and future, new books on nursing. and the impact that coaching can have on nurses' lives, among other topics of note. I look forward to continuing to deliver quality content that's informative, timely, and easy to read (and perhaps periodically entertaining).

Thank you for supporting Digital Doorway. Thanks for reading, thanks for the many comments, for following me on Facebook and Twitter, and for the encouraging words I've received since launching NurseKeith.com.

Yes, it's been a long, strange trip, and I have a feeling 2012 will be no different. Come along for the ride, and let's see what the next seven years brings!

Sunday, January 15, 2012

Just a reminder that tomorrow, January 16th, 2012, Andrew Lopez of Nursefriendly.com will be our guest on RN.FM Radio. Andrew is the consummate connector and promoter of nurses, and we look forward to his appearance on RN.FM Radio! Tune in or listen to the archived show afterwards.

Wednesday, January 11, 2012

A note to the reader: As always, I have received no remuneration for
posting this book review. As a point of disclosure, I did, however,
receive a free copy of the book from the author in order to facilitate
the review process.

In Confident Voices, Boynton strives to give nurses the understanding and skills to navigate the workplace in a way that fosters improved communication, healthier workplaces and a more supportive and safe environment for them and their colleagues. Boynton achieves her goal, and delivers information that is useful, well-organized, easy to digest, and potentially possible to put into practice immediately.

The book walks the reader through three distinct sections covering various topics of interest to the nurse who wishes to work in an environment that supports positive relationships and respectful communication.

Part I addresses workplace dynamics, and identifies the characteristics of toxic workplaces, and delves into theories that explain human behavior, especially in the context of the workplace. Organizational culture is explained and dissected, and workplace violence---be it physical, verbal or emotional---is also addressed.

Part II is focused on "building assertiveness and respectful listening skills" and explores "strategies for creating organizational cultures where effective communication and respectful relationships can thrive".

Part III integrates the theories, insights and skills covered in Parts I and II in the context of nurses' experiences which were gleaned from interviews with nurses in the field. Common toxic behaviors are described and various revisions of the encounters in question are offered as examples of improved communication and healthier outcomes for all involved.

Discussion

Toxicity in the workplace is an important subject rarely given its due, and Boynton succeeds in communicating her mission clearly in this very useful book. We all know that the health care system is suffering from various forms of overload and dysfunction, and the result for nurses is that we often feel powerless in the face of old patriarchal systems of organization, entrenched methods of communication, and hierarchical relationships that apparently strip us of our power and leave us literally speechless in the face of workplace violence, bullying, top-down management, and organizational failure.

Boynton gives nurses concrete examples of common situations wherein nurses can practice their assertiveness and respectful communication skills. She also provides practical tools for nurses within a theoretical framework that takes into consideration the characteristics of toxic workplaces, the ways in which workplace violence impacts nurses, and how effective communication can cut through the static to a place of greater clarity, personal empowerment, and professional satisfaction.

In a future edition of "Confident Voices", I would like to see the author make use of a more diverse selection of real-life scenarios in order to address potential gender and power issues that her examples fail to take into consideration.

Suggestions

The nurse interviews used in the book to illustrate Boynton's thesis all feature female nurses who are interacting with male physicians in the hospital setting. While this gender dynamic may be common (and may be a deeply and culturally embedded knee-jerk reaction when we think of "nurse and doctor") there are now a plethora of female physicians working alongside male nurses, and male nurses working alongside male physicians.

Additionally, it would be interesting to explore workplace dynamics when we consider male and female nurses working together, as well as combinations of male nurses alongside male nurses, and female nurses collaborating with female doctors. It could also be enlightening to explore the dynamics of workplace violence, bullying and communication when considering comparisons between male and female supervisors and administrators, and the ways in which gender differences impact communication in health care. Several books have been written about the effects of feminism on the nursing profession, most notably "Daring to Care: American Nursing and Second-Wave Feminism" by Susan Gelfand Malka. Perhaps an exploration combining the effects of feminism on nursing and changes in communication would be an interesting follow up to "Confident Voices".

Within "Confident Voices", Boynton also does not address cultural, ethnic and racial differences in communication that could greatly impact nurses and those who work in health care institutions. Asians, Native Americans, Hispanics and other groups may have cultural practices and norms vis-a-vis communication that differ widely from white American culture. From eye contact to body language, communication in the workplace also needs to take these differences into consideration.

My Recommendation

Overall, I would highly recommend "Confident Voices" to any nurse who wishes to improve his or her own communication skills, share those skills with colleagues, and attempt to understand organizational culture with an eye towards creating positive workplaces for all concerned.

On the Radio

Beth Boynton will be appearing as a guest on RN.FM Radio: Nursing Unleashed on March 12th, 2012 at 9pm EST. Please tune in and you will be able to call into the show and ask Beth questions about her work as a nurse, writer, and workplace communication expert.

Monday, January 09, 2012

Today, on Monday the 9th of January, 2012 at 9pm EST, RN.FM Radio will launch its inaugural broadcast on Blog Talk Radio. RN.FM Radio is the newest voice to emerge vis-a-vis the cutting edge of the nursing profession, and RN.FM Radio will bring to the airwaves the most diverse mix of entrepreneurs, bloggers, coaches, writers and thought leaders within the nursing community.

The show will be hosted by myself, as well as Anna Morrison of I Coach Nurses, and Kevin Ross of Innovative Nurse. As nurse entrepreneurs, our mission is to forge a new vision of nursing and what it means to be a nurse in the 21st century.

Please tune in tonight, January 9th at 9pm EST on Blog Talk Radio, or listen to the archived shows afterwards. All shows will include the opportunity for listeners to call in and offer questions or comments, or participate in live chats with other listeners.

Please watch for the launch of our website, RNFMRadio.com, and you can also connect with us on Facebook and Twitter!

RN.FM Radio is the new voice of nursing. Join us as we forge a new vision of nursing in the 21st century!

Tuesday, January 03, 2012

The following letter is being sent to all members of Congress to enlist their support of The National Nurse Act of 2011. If you would like to be a signatory to this letter, please contact Terri Mills, President of the
National Nursing Network Organization, whose contact information is listed below.

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To The Members of the United States Congress:

We,
the undersigned, urge you to support HR 3679 The
National Nurse Act of 2011. This legislation
would designate the Chief Nurse Officer of the U.S. Public Health Services
as the "National Nurse for Public Health" to elevate the authority
and visibility of this position. Chronic conditions such as diabetes, asthma,
obesity, and others pose the single greatest threat to the health of Americans
and our nation's economy. Nurses provide key services for the prevention and
management of these conditions and this legislation is necessary
to support further work needed to promote prevention, improve
outcomes, and guide national, state and local efforts in addressing
the nation's health.

This
is the ideal time to make a National Nurse for Public Health a reality.
The current administration and Congress have a clear commitment to wellness
promotion and illness prevention. There is convincing evidence that the
health of our country can be dramatically advanced by deploying our greatest
and most trusted national health resource, America's nurses. Establishing a
National Nurse for Public Health would be a practical step forward in publicly
acknowledging the need for a focus on wellness and prevention.
This legislation would provide the nation with
a trusted professional representative from nursing to kickoff
the move to prevention in whatever form of health-care system our
lawmakers deliver.

The
National Nurse for Public Health would provide a visible nurse leader to
advocate for enhanced prevention efforts for all communities. Further, we
recognize the potential of having the National Nurse for Public Health as a
representative who would meet with health care leaders
to determine ways to address continued health disparities and
poor health literacy.

We,
as organizations and individuals, support this legislation as a means to
achieve the goals of better health, decreased health disparity and improved health
literacy and look forward to working with you on this important issue. We
applaud your efforts in highlighting the important contribution of nurses
and in your advocacy of improvement of the nation’s health. We strongly
urge your support of The National Nurse Act of 2011.

Thank you for your consideration and please call upon us if we
can be of further support as this bill moves forward.

Monday, January 02, 2012

As nurses, when we are preparing to walk into an exam room, a hospital room, or a patient's home, we bring with us a veritable toolbox of skills, ranging from biopsychosocial analysis to keen physical assessment skills. We are trained to look at the whole patient, the family system, and the multifaceted aspects of patients' lives.

However, we can also walk through that door with judgments, suspicions, preconceived beliefs, fears, projections, and a host of other "baggage" that may or may not serve the therapeutic relationship---nor our patient's chances of healing.

In my own work, I have witnessed patients and their families engaged in drug addiction, prostitution, child neglect, elder abuse, financial exploitation, and numerous other social conditions or actions that could often make my skin crawl. I also witnessed patients simply making poor choices, living in squalid conditions, refusing treatment, and otherwise choosing chaos over order, illness over health, and hell over healing.

When possible and necessary, I would intervene, and sometimes that meant calling the police or the local protective service organization. Sometimes it meant just listening and trying to get to the root of the behavior. At others, it was a call to a therapist, a psychiatrist, or a drug counselor.

No matter the situation, we health care providers bring to the situation our own life experiences, our own traumas, and a unique personal history. In this line of work, transference and projection are not just quaint vocabulary terms memorized during a requisite Psych 101 class, and if you're a nurse and you can't tell me what projection and transference are, then it's time to do some brushing up. (Perhaps that Psych 101 textbook is still in your garage somewhere.)

No matter where you are in the course of your career, you are subject to the same psychological forces as a novice nurse, and at times it is exactly our experience as seasoned nurses that can harm us the most. Cynicism, jadedness, and a sense of "I've seen it all before" can actually get in the way of our seeing the patient for who they are in the first place, so looking beyond our experience with fresh eyes and an open heart can work wonders for actually "seeing" the patient or situation in front of our very noses.

Before you walk in that door, think about what it is that you bring to the therapeutic relationship and the situaton at hand. What is the baggage that might get in the way? What are the stresses and worries from outside of work that need to be set aside? And once you're in that room, keep a sharp eye out for those projections, that sneaky transference, and the judgments that undermine your ability to be objective and most clinically effective.

And remember to ask yourself: What am I bringing to this encounter? What are the skills that I most need to activate at this time? And what do I need to leave outside that door?

The Nurse Keith Show

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Welcome to Digital Doorway!

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